Can Dialysis Patients Be Accurately Identified Using Healthcare Claims Data?

♦ Background: While health insurance claims data are often used to estimate the costs of renal replacement therapy in patients with end-stage renal disease (ESRD), the accuracy of methods used to identify patients receiving dialysis — especially peritoneal dialysis (PD) and hemodialysis (HD) — in these data is unknown.♦ Methods: The study population consisted of all persons aged 18 - 63 years in a large US integrated health plan with ESRD and dialysis-related billing codes (i.e., diagnosis, procedures) on healthcare encounters between January 1, 2005, and December 31, 2008. Using billing codes for all healthcare encounters within 30 days of each patient’s first dialysis-related claim (“index encounter”), we attempted to designate each study subject as either a “PD patient” or “HD patient.” Using alternative windows of ± 30 days, ± 90 days, and ± 180 days around the index encounter, we reviewed patients’ medical records to determine the dialysis modality actually received. We calculated the positive predictive value (PPV) for each dialysis-related billing code, using information in patients’ medical records as the “gold standard.”♦ Results: We identified a total of 233 patients with evidence of ESRD and receipt of dialysis in healthcare claims data. Based on examination of billing codes, 43 and 173 study subjects were designated PD patients and HD patients, respectively (14 patients had evidence of PD and HD, and modality could not be ascertained for 31 patients). The PPV of codes used to identify PD patients was low based on a ± 30-day medical record review window (34.9%), and increased with use of ± 90-day and ± 180-day windows (both 67.4%). The PPV for codes used to identify HD patients was uniformly high — 86.7% based on ± 30-day review, 90.8% based on ± 90-day review, and 93.1% based on ± 180-day review.♦ Conclusions: While HD patients could be accurately identified using billing codes in healthcare claims data, case identification was much more problematic for patients receiving PD.     

When Should You Test for and Treat Hypoglycemia in Prehospital Seizure Patients?

Abstract

Objectives. Seizure is a frequent reason for activating the Emergency Medical System (EMS). Little is known about the frequency of seizure caused by hypoglycemia, yet many EMS protocols require glucose testing prior to treatment. We hypothesized that hypoglycemia is rare among EMS seizure patients and glucose testing results in delayed administration of benzodiazepines. Methods. This was a retrospective study of a national ambulance service database encompassing 140 ALS capable EMS systems spanning 40 states and Washington DC. All prehospital calls from August 1, 2010 through December 31, 2012 with a primary or secondary impression of seizure that resulted in patient treatment or transport were included. Median regression with robust and cluster (EMS agency) adjusted standard errors was used to determine if time to benzodiazepine administration was significantly related to blood glucose testing. Results. Of 2,052,534 total calls, 76,584 (3.7%) were for seizure with 53,505 (69.9%) of these having a glucose measurement recorded. Hypoglycemia (blood glucose <60 mg/dL) was present in 638 (1.2%; CI: 1.1, 1.3) patients and 478 (0.9%; CI: 0.8, 1.0) were treated with a glucose product. A benzodiazepine was administered to 73 (11.4%; CI: 9.0, 13.9) of the 638 hypoglycemic patients. Treatment of seizure patients with a benzodiazepine occurred in 6,389 (8.3%; CI: 8.1, 8.5) cases and treatment with a glucose product occurred in 975 (1.3%; CI: 1.2, 1.4) cases. Multivariable median regression showed that obtaining a blood glucose measurement prior to benzodiazepine administration compared to no glucose measurement or glucose measurement after benzodiazepine administration was independently associated with a 2.1 minute (CI: 1.5, 2.8) and 5.9 minute (CI: 5.3, 6.6) delay to benzodiazepine administration by EMS, respectively. Conclusions. Rates of hypoglycemia were very low in patients treated by EMS for seizure. Glucose testing prior to benzodiazepine administration significantly increased the median time to benzodiazepine administration. Given the importance of rapid treatment of seizure in actively seizing patients, measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by our study. EMS seizure protocols should be revisited.     

Prehospital Nitroglycerin in Tachycardic Chest Pain Patients: A Risk for Hypotension or Not?

Background: The American Heart Association guidelines (AHA) guidelines list tachycardia as a contraindication for the administration of nitroglycerin (NTG), despite limited evidence of adverse events. We sought to determine whether NTG administered for chest pain was a predictor of hypotension (systolic blood pressure <90 mmHg) in patients with tachycardia, compared to patients without tachycardia (50≥ heart rate ≤100). Methods: We performed a retrospective cohort study using patient care reports completed by basic life support (BLS) providers in a large urban Canadian EMS system for the period 2010–2012. We used logistic regression to test the association between post-NTG hypotension and tachycardia, independent of pre-NTG blood pressure, age, sex, and comorbidities. Using identical models, we tested four secondary outcomes (drop in blood pressure, reduced consciousness, bradycardia, and cardiac arrest). Results: The cohort included 10,308 patients who were administered NTG by BLS in the prehospital setting; 2,057 (20%) of patients were tachycardic before NTG administration. Hypotension occurred in 320 of all patients (3.1%): 239 without tachycardia (2.9%) and 81 with tachycardia (3.9%). Compared to non-tachycardic patients, tachycardic patients showed increased adjusted odds of hypotension (AOR: 1.60; 95% CI: 1.23–2.08) or of a drop in blood pressure of 30mm Hg or greater (AOR: 1.11; CI: 1.00–1.24). Tachycardia was associated with decreased odds of bradycardia (OR: 0.33; CI: 0.17–0.64). We did not find a significant association between tachycardia and either post-NTG reduced level of consciousness or cardiac arrest. We did find a strong, significant association between pre-NTG blood pressure and post-NTG hypotension (AOR for units of 10mmHg: 0.64; CI: 0.61–0.69). Conclusion: Hypotension following prehospital administration of NTG was infrequent in patients with chest pain. However, while the absolute risk of NTG-induced hypotension was low, patients with pre-NTG tachycardia had a significant increase in the relative risk of hypotension. In addition, hypotension occurred most frequently in patients presenting with a lower pre-NTG blood pressure, which may prove to be a more discriminating basis for future guidelines. EMS medical directors should review BLS chest pain protocols to weigh the benefits of NTG administration against its risks.     

When are Prehospital Intravenous Catheters Used for Treatment?

Prior studies have found that > 50% of prehospital intravenous catheters (i.v.s) were unutilized for treatment; however, few data are available regarding which patients benefit. The objective of this study was to examine the association between i.v. utilization in the field, paramedic primary impression, and patient presentation. Prehospital records for 34,585 patients were evaluated for i.v. placement and utilization in the field. Logistic regression was used to evaluate the association of primary impression, systolic blood pressure, heart rate, respiratory rate, Glasgow Coma Scale score, skin sign color, and capillary refill with placement and utilization. Intravenous catheters were placed in 60% of patients, but only 17% of the total was utilized. Examples of primary impressions with frequent initiation and low utilization (n = number in group, % of total with i.v. placed, % of total used): post-seizure (n = 989, 72%, 9%); weakness/dizzy/nausea (n = 3092, 69%, 20%), syncope/near-syncope (n = 2034, 81%, 26%), and abdominal pain (n = 1554, 70%, 14%). Fifty-eight percent with normal vital signs received an i.v. and 28–30% were utilized; hypotension: 80% received i.v. (odds ratio [OR] 1.211, p = 0.012), 70% utilized; hypertension: 61% received i.v. (OR 1.060, p = 0.027), 28% utilized; bradycardia: 82% received i.v. (OR 1.588, p < 0.0001), 51% utilized; tachycardia: 66% received i.v. (OR 1.152, p = 0.001), 33% utilized; bradypnea: 93% received i.v. (OR 1.638, p = 0.051), 86% utilized; tachypnea: 70% (OR 1.120, p = 0.024), 33% utilized. A Glasgow Coma Scale score < 15: 76% received i.v. (OR 1.672, p < 0.0001), 32% utilized. Abnormal skin color: 79% received i.v. (OR 1.691, p < 0.0001), 42% utilized. Certain primary impressions are associated with high i.v. initiation rates but infrequent utilization. High utilization rates were associated with hypotension, bradycardia, bradypnea, and abnormal skin signs. Study of high-frequency, low-utilization groups could reduce unnecessary i.v. placement.     

Can Older Adults Accurately Report Their Use of Physical Rehabilitation Services?

Objective

To explore the accuracy of rehabilitation service use reports by older adults as well as variation in accuracy by demographic characteristics, time since use, duration, and setting (inpatient, outpatient, home).

Is a Prehospital Treat and Release Protocol for Opioid Overdose Safe?

Background

The current standards for domestic emergency medical services suggest that all patients suspected of opioid overdose be transported to the emergency department for evaluation and treatment. This includes patients who improve after naloxone administration in the field because of concerns for rebound toxicity. However, various emergency medical services systems release such patients at the scene after a 15- to 20-min observation period as long as they return to their baseline.

Does Prehospital Time Influence Clinical Outcomes in Severe Trauma Patients?: A Cross Sectional Study

Objective: Prehospital time potentially impacts clinical outcomes in severely injured trauma patients. The importance of individual components, including scene and response time, however, is controversial. Our objective was to determine the impact of prehospital times on survival in severely injured patients. Methods: We reviewed injured trauma patients enrolled in a Korean EMS trauma registry during 2012. Severe trauma patients were defined as having either a “V” or lower in the AVPU system, a systolic blood pressure ≤90mmHg, or respiratory rate <10 or >29. Patients with Injury Severity Scores(ISS) < 9 were excluded. Patients were categorized by scene time into 4 groups as follows: <3 minutes, 3–6 minutes, 6–9 minutes, and ≥9 minutes and by prehospital time as follows: <16 minutes, 16–24 minutes, 24–32 minutes, and ≥32 minutes. The primary outcome was in-hospital mortality. Multiple linear regression analysis was used to adjust for possible confounders. Results: A total of 2,257 eligible patients were analyzed. Scene time was <3 minutes in 220 (9.7%), 3–6 in 865 (38.3%), 6–9 in 587 (26.0%), and ≥9 in 585 (25.9%). In-hospital mortality was 396 (17.5%). Compared to a scene time 6 to 9 minutes, mortality was higher as the scene time decreased: odds ratio (OR) = 1.3(3 to <6), OR = 1.9(0 to <3). Mortality was slightly decreased as prehospital time increased, OR = 1.0(16 to <24), OR = 0.9(24 to <32), OR = 0.7(≥32). Conclusion: Longer prehospital times did not increase mortality in severely injured trauma patients in Korea. Furthermore, longer scene times were associated with lower mortality.     

Can Intraocular Pressure Measurements be Used to Screen for Elevated Intracranial Pressure in Emergency Department Patients?

Background

Handheld measurement of intraocular pressure (IOP) has been previously shown to accurately predict elevated intracranial pressure (ICP) in neurosurgical patients. Handheld tonometry may have clinical utility in the prediction of elevated ICP among a cohort of emergency department (ED) patients receiving lumbar puncture (LP).

Objective

To ascertain the sensitivity and specificity of IOP for the prediction of elevated ICP in ED patients undergoing LP.

Methods

In this prospective observational pilot study, all ED patients over the age of 18 years and undergoing LP in the ED for any reason were eligible to participate. Study participants had IOP measured with the Tono-Pen XL (Reichert, Inc., Depew, NY) while in the supine position before LP. OP was measured in the lateral recumbent position. Elevated IOP was defined as ≥ 20 mm Hg; elevated ICP was defined as ≥ 20 mm H₂O.

Results

There were 82 patients screened and 46 patients enrolled at the time of interim analysis. Of the 46 patients, 32 had a successful LP in the lateral recumbent position. There were 18/32 patients with a successful LP in the lateral recumbent position who had elevated opening pressure; 9/32 patients with a successful LP had an elevated IOP. Furthermore, 4/9 patients with elevated IOP also had an elevated opening pressure. There was only one patient who had elevated IOP, elevated ICP, and diagnostic cerebrospinal fluid (sensitivity 24%, 95% confidence interval [CI] 9–48%; specificity 63%, 95% CI 32–88%; positive predictive value 28%, 95% CI 14–47%; negative predictive value 72%, 95% CI 53–96%).

Conclusions

Handheld tonometry has poor sensitivity and specificity for the prediction of increased ICP, and should not be used as a screening tool in the ED.     

Can You Catch It? Lessons Learned and Modification of ED Triage Symptom- and Travel-Screening Strategy

IntroductionEfficient identification and isolation of patients with communicable diseases limits exposure to health care workers, other patients, and visitors. In August 2014, our team developed and implemented an algorithm to triage suspected cases of Ebola virus disease in a midwestern United States emergency department and outpatient clinics based on patient travel history and symptoms. Here, we present the lessons learned and modifications to update the tool.MethodsTwo strategies were developed and utilized to properly identify, isolate, and inform on patients with suspected highly hazardous communicable diseases: 1) a robust electronic symptom and travel screen with decision support tools in the electronic medical record, and 2) the availability of workflow protocols for Ebola virus disease, Middle East Respiratory Syndrome (MERS), and coronavirus 2019 (COVID-19) once a person under investigation is identified. After action reports provided opportunities to modify the algorithm and improve the identification and isolation processes.ResultsSince our screening and travel electronic medical record inception 5 years ago, modifications changed iteratively to further enhance the screening process. Since 2018, staff have identified 5 patients at risk for MERS; in all cases, identification occurred during the check-in process. Exposure investigations in the emergency department decreased significantly after algorithm implementation in January 2019, from 30 in 2018 to 0 in 2019.DiscussionAlthough highly hazardous communicable diseases like Ebola virus disease and MERS are of concern due to their mortality rates and limited treatment options, these same concepts may be applied to the early identification and isolation of patients suspected of having more common communicable diseases like measles and influenza, emphasizing the importance of protocol-based screening in the healthcare environment.     

Where in the Brain do Strokes Occur? A Pilot Study and Call for Data

Background: Every year, more than 795,000 people in the United States have a stroke, and each year about 140,000 Americans die from strokes. Although there is abundant information on the epidemiology, risk factors, pathophysiology, and many clinical features of strokes, there is a lack of specific numerical quantitation on the neuroanatomical distribution of strokes.Methods: This retrospective study utilized de-identified reports of radiologic imaging to determine the neurovascular anatomical location of acute ischemic cerebral infarcts in a 637-bed regional hospital in a rural area during the one-year interval from October 1, 2018 through September 30, 2019.Results: During the one-year study period, there were 418 acute ischemic strokes, and 54.6% (228/418) were in the territory of a single large vessel. Of the single large vessel strokes, 62.3% (142/228) were in a middle cerebral artery (MCA) territory, 12.1% (29/228) in a posterior cerebral artery (PCA) territory, 8.8% (20/228) in a basilar artery distribution, 7.5% (17/228) in a posterior inferior cerebellar artery (PICA) distribution, 6.6% (15/228) in an anterior cerebral artery (ACA) distribution, 1.8% (4/228) in a superior cerebellar artery (SCA) distribution, and 0.4% (1/228) in an anterior inferior cerebellar artery (AICA) territory. Internal capsule lacunar strokes accounted for 17.7% (74/418) of the total, brainstem lacunar strokes for 8.1% (34/418) and thalamic lacunar strokes for 5% (21/418) of the infarctions. Watershed infarctions accounted for 2.9% (12/418) of the strokes, 9 in the MCA/PCA watershed area and 3 in the MCA/ACA watershed area.Conclusions: This pilot study illustrates a methodology for collecting data to substitute specific numerical quantitation for vague generalities about the neuroanatomical distribution of strokes. Such quantification can enable evidence-based data-driven improvements in the care of stroke patients.     

Can Benign Etiologies Predict Benign Outcomes in High-Risk Syncope Patients?

Background: We previously studied and validated risk factors for adverse outcomes or need for critical intervention in syncope. Objective: To determine whether high-risk patients, diagnosed with benign etiologies of syncope after a normal emergency department (ED) work-up, sustain favorable outcomes. Methods: Prospective, observational cohort of consecutive ED patients aged ≥ 18 years with syncope. Benign etiology was defined as vasovagal syncope or dehydration. Patients were followed up to 30 days to identify adverse outcomes including death, myocardial infarction, dysrhythmia, alterations in antidysrhythmics, percutaneous intervention, pulmonary embolus, stroke, metabolic catastrophe, or significant hemorrhage. Results: Patients presented with benign etiologies in 164/293, 56% (95% confidence interval [CI] 50–62%) of cases. Of these, pathologic conditions were identified during ED evaluation in 11/164, 7% (95% CI 3–11%) of cases. This includes ED findings/treatments of blood transfusion, severe electrolyte disturbance, incarcerated hernia, rhabdomyolysis, subarachnoid hemorrhage, bowel obstruction, dysrhythmia, and transient ischemic attack. The remaining 153 with benign presentations had no adverse outcomes at 30 days, while 57/129 (44%) patients with non-benign etiologies had adverse outcomes in the hospital or within 30 days. Previously, we demonstrated a 48% reduction in admission rate if only patients with risk factors for adverse outcome were admitted. If patients with both benign etiologies and a negative ED work-up were sent home, even if they had risk factors for an adverse outcome, an additional 19% (95% CI 14–25%) reduction in hospital admissions would have occurred. Conclusions: In patients with presentations consistent with a benign etiology of syncope (vasovagal or dehydration) where the ED work-up was normal, we found no patients who would benefit from hospitalization based on risk factors alone.     

Can Journaling Provide Support for NICU Families?

Column Editor: Linda Franck Family‐Centered Care provides a forum for sharing information about basic components of caring for children and families, including respect, information sharing, collaboration, family‐to‐family support, and confidence building.